Gastrointestinal pathologists’ perspective on managing risk in the distal esophagus: convergence on a pragmatic approach

Abstract

Here, we discuss recent updates and a continuing controversy in the diagnosis and management of Barrett's esophagus, specifically the recommendation that the irregular Z-line not be biopsied, the diminished status of ultrashort-segment Barrett's esophagus, the evidence basis for excluding and including the requirement of goblet cells for the diagnosis of Barrett's esophagus, and the conclusion that histologically confirmed low-grade dysplasia is best managed with endoscopic ablation rather than surveillance. We reference the American Gastroenterological Association and College of Gastroenterology and the British Society of Gastroenterology guidelines throughout, with the thesis that the field is converging on the concept of applying scarce medical resources to the diagnosis, surveillance, and therapy of patients most likely to derive benefit.

Dysplastic Barrett’s Esophagus: Surveillance, Treatment and Follow-Up Care

“…10,21,24 Therefore, the AGA recommends periodic surveillance at an interval of 6 to 12 months as the first line of treatment. 8,19,20 On the other hand, an interval of only 6 months is recommended by the Australian guideline and the Asia-Pacific Consensus and supported by the study carried out by Jia et. al.…”

“…13,15 To optimize this assessment, all the guidelines recommend using the Seattle Protocol, which consists of biopsying four quadrants obtained every 2 cm for patients without dysplasia and every 1 cm for patients with previous dysplasia. 15,17,19,20 However, this protocol has some challenges. One is that surveillance from random biopsies only shows a small proportion of the Barrett's Esophagus mucosa.…”

“…13,16,18,22,23 Another consensus among international guidelines is that any visible dysplastic lesion, whether low-grade or high-grade, should be diagnosed by at least two pathologists, one of whom should be a specialist in gastrointestinal pathology and use a highquality endoscopic technique to confirm the diagnosis. 8,9,13,14,18,20,22,23 This recommendation was established in order to minimize the chances of misdiagnosis, since low-grade dysplasia can often be confused with nondysplastic BE even among experienced pathologists. 13,24 Even though, for diagnostic confirmation, the British Society of Gastroenterology (BSG), the European Society of Gastrointestinal Endoscopy (ESGE) and the Australian guideline recommend repeating the same endoscopic evaluation in 6 months.…”

The indications for biopsy in routine upper gastrointestinal endoscopy

“…This remains contentious, not least because of poor interobserver agreement levels regarding what constitutes IM in routinely assessed biopsies (Figure 3). 35,36 However, these developments demonstrate much closer alignment between UK and North American practice than hitherto 37 …”

“…35,36 However, these developments demonstrate much closer alignment between UK and North American practice than hitherto. 37 So, if the histological features of Barrett's oesophagus are not specific to that disease, with potentially identical changes being seen in mucosa from the proximal stomach, and if we accept that no adjunctive test, whether histochemical, immunohistochemical, or otherwise, shows diagnostic features of Barrett's oesophagus, 38,39 some have questioned whether biopsies are required at all, at the index endoscopy, when classic Barrett's oesophagus has been demonstrated endoscopically. Indeed, one of us has argued that perhaps the most important indication for such biopsies is the demonstration of dysplasia complicating CLO, as this is occasionally seen at the index endoscopy.…”